CMS SOM App. H, Tag V540

Interpretive Guidance § 494.90

The Condition is directly related to the Condition for patient assessment, as the plan of care is

built upon the patient assessment. The individual plan of care is revised after each patient

assessment, and portions of the plan must be updated if the target goals for each area are not

achieved or sustained.

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The Condition for patient plan of care reviews individual patient outcome data and addresses the

goals and plans set for individual patients, while the Condition for quality assessment and

performance improvement (QAPI) reviews aggregate data for trends and commonalities and

addresses facility-wide goals and improvement plans.

Survey tasks, including observation, patient and staff interviews, and medical record review, are

used to evaluate compliance with this Condition. Identification of issues such as lack of blood

pressure monitoring at the frequencies required by facility policy or as indicated by the patient’s

condition, or the failure to respond to hypertension or hypotension, may indicate a failure to

develop or implement a portion of the plan of care. Each patient should be treated individually.

When a specified target is not met, the plan of care should either be adjusted to achieve the

target or an explanation provided by the IDT in areas where the target cannot be met.

Examples of condition-level noncompliance would include, but not be limited to:

• Serious and/or pervasive deficient practices identified in the development or

implementation of individualized plans of care;

• A pattern of failure to revise the applicable portion of the plans of care when the current

plan did not result in achieving or sustaining the intended outcome; or,

• A pattern of failure in updating the plans of care when indicated by the patient’s

condition.